Conjoined Twins are Separated Successfully at the University of Maryland Hospital for Children

A 35-member team from the University of Maryland Hospital for Children in Baltimore, led by Marcelo Cardarelli M.D., a cardiac surgeon, and Eric Strauch, M.D., a pediatric surgeon, separated 6-month-old conjoined twin girls from Africa on April 19, 2002. Surgeons, anesthesiologists, cardiologists, nurses, OR technicians, biomedical engineers, and even electricians worked for more than 12 hours to achieve the successful separation of Loice and Christine Onziga.

BEFORE: The conjoined twin girls were connected from the breast bone to the navel, and shared a liver and a main blood vessel that connected their hearts.

AFTER: Loice and Christine were separated successfully after a 12-hour surgery at the UM Medical Center. The girls are healthy and should develop normally, their doctors say.

Loice and Christine were born connected from the breast bone to the navel. This type of connection is classified as thoracopagus, and is the most common connection in conjoined twins. Loice, the smaller of the two girls, and Christine, each had their own spleen, kidneys and gallbladder. However, they shared a diaphragm, sternum, chest wall and abdominal wall. They had a fused liver, which had to be separated and their hearts were connected by a large blood vessel.

"Their hearts were flipped around, in an abnormal position, and encased in a common sack. None of the imaging tests we performed before surgery could tell us exactly what we would find. It was only when we got inside that we learned the two girls shared a large vein," says Marcelo Cardarelli, M.D., an assistant professor of surgery at the University of Maryland School of Medicine and a cardiac surgeon at the University of Maryland Medical Center.

Loice and Christine Onziga were born on October 28, 2001. Their mother, Margret, was prepared to deliver what she thought was one baby at home, which is customary in Africa.

But there were complications and Margret went to a nearby village, where not one, but two girls were delivered by cesarean section.

When Loice and Christine were just 11 days old, Margret boarded another bus with the girls. They were not headed home; instead they were bound for Mulayo Hospital in the capital city of Kampala.

When the family arrived in Kampala, Dr. Margaret Nakakecto and her team of pediatric specialists at the local university hospital evaluated the twins and thought they could be successfully separated. The family was then introduced to Cindy Howard, M.D., a clinical assistant professor of pediatrics at the University of Maryland School of Medicine. Dr. Howard was in Kampala as part of an exchange program, joined by Sherri Shubin, M.D. and Sue Rhee, M.D., senior pediatric residents from the University of Maryland Medical Center, who were there as part of their training.

Four months after that meeting, Dr. Howard and another pediatric resident accompanied the family on the long journey from Uganda to Baltimore to have their daughters surgically separated at the University of Maryland Hospital for Children.

"It was unrealistic that the girls would live a long life as conjoined twins in Africa," says Dr. Howard. The doctors who saw Loice and Christine in Uganda suggested the girls' chances of living a normal, healthy life would be increased if they were separated.

Six weeks after arriving in the United States and following many pre-operative tests, Loice and Christine were taken into the operating room for surgery. The surgical team had spent many hours preparing for the separation, including a practice run several days beforehand to make certain that all staff and equipment were ready.

"This was an extra challenging surgery because we needed to care for two patients at the same time instead of just one," says Anne Savarese, M.D., director of pediatric anesthesiology at the University of Maryland Hospital for Children and assistant professor of anesthesiology at the University of Maryland School of Medicine. She and Monique Bellefleur, M.D., another pediatric anesthesiologist, worked as a team before, during and after the surgery to ensure the twins' safety.

On the day of the surgery, it took more than six hours to prepare the babies for the separation. The first incision was made in the early afternoon. Drs. Cardarelli, Strauch, and the team began with the abdomen. They separated the girls' liver. Then they continued upward to the chest. The surgeons found that the upper chambers of Loice and Christine's hearts were connected, a situation for which the surgeons were prepared. Their hearts and the connecting vessels were separated last.

"We first had to clamp the vein connecting both girls' hearts, as a test, to see if their blood pressure and oxygen levels would remain steady, and assure that their hearts would continue beating. We were relieved to find out that we could cut this pathway of life between them, without causing harm," says Bartley Griffith, M.D., Chief of Cardiac Surgery at the University of Maryland Medical Center and professor and head of the Division of Cardiac Surgery at the University of Maryland School of Medicine.

Less than four hours after the first incision, the girls were separated. Loice and Christine were then transferred to different operating tables where the physicians and nurses began the process of closing their abdomens and chests. The two teams of surgeons used a synthetic material to reconstruct part of the diaphragm, chest, and abdominal walls.

Just a few hours later, Loice and Christine were taken to the University of Maryland Hospital for Children's Pediatric Intensive Care Unit to continue their recovery under the watchful eyes of the attending physicians and nurses.

"It went as well as we had hoped it would," says Eric Strauch, M.D., an assistant professor of surgery at the University of Maryland School of Medicine, when he reflects on the surgery. "The girls are doing very well. We just need to monitor them closely," he adds.

Conjoined twins occur roughly once in every 200,000 live births in the United States. They are identical twins who develop with a single placenta from one fertilized egg. These cases occur more often in Africa and India than in the United States. Many sets of conjoined twins cannot be separated because they share vital organs.

Loice and Christine are actually the second set of conjoined twins to be separated at the University of Maryland Medical Center. In June 1986, a 24-member team led by pediatric surgeon Dr. J. Laurence Hill successfully separated 2-month-old Baltimore girls who shared a liver, diaphragm, chest wall and heart sac. Just like Loice and Christine, these girls were connected from the chest to the abdomen. Now, 16 years later, those twins are healthy and leading active lives.

Every person who took part in the surgery of Loice and Christine offered their services free of charge. "I cannot overemphasize the enthusiasm and expertise among the physicians and staff who have participated in caring for the twins," says Jay Perman, M.D., head of the University of Maryland Hospital for Children and professor and chair of Pediatrics at the University of Maryland School of Medicine.

"This operation demonstrates our ability to manage the most complicated and challenging cardiac conditions, and is an example of this medical center's overall expertise, creativity and compassionate care," according to Dr. Griffith.

In addition to the doctors and nurses on the surgical team, operating room technicians, biomedical engineers, security personnel, and facility engineers were instrumental in making the surgery a success.

Many pediatricians, nurses, radiologists, growth and nutrition experts, and physical therapists at the University of Maryland Hospital for Children also played an essential role in caring for Loice and Christine, both before and after the operation.

Those who helped the family include the University of Maryland Medical Center, the University of Maryland School of Medicine, Mulago Hospital in Kampala, Makerere University School of Medicine in Kampala, the Nieves Foundation, the Woods Memorial Presbyterian Church, Sisters of Mercy, Baltimore Region, and the Ronald McDonald House Charities of Baltimore.

Learn more about conjoined twins, read about the other set of conjoined twins successfully separated at the UM Medical Center and much more in our conjoined twins guide.

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